McLaughlin and Kaluzny’s Continuous Quality Improvement in Health Care FIFTH EDITION Julie K Johnson, PhD, MSPH Professor, Department of Surgery Center for Healthcare Studies Institute for Public Health and Medicine Feinberg School of Medicine, Northwestern University Chicago, Illinois William A Sollecito, DrPH Clinical Professor, Public Health Leadership Program UNC Gillings School of Global Public Health University of North Carolina at Chapel Hill Chapel Hill, North Carolina World Headquarters Jones & Bartlett Learning Wall Street Burlington, MA 01803 978-443-5000 info@jblearning.com www.jblearning.com Jones & Bartlett Learning books and products are available through most bookstores and online booksellers To contact Jones & Bartlett Learning directly, call 800-832-0034, fax 978-443-8000, or visit our website, www.jblearning.com Substantial discounts on bulk quantities of Jones & Bartlett Learning publications are available to corporations, professional associations, and other 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advertising or product endorsement purposes All trademarks displayed are the trademarks of the parties noted herein McLaughlin and Kaluzny’s Continuous Quality Improvement in Health Care, Fifth Edition is an independent publication and has not been authorized, sponsored, or otherwise approved by the owners of the trademarks or service marks referenced in this product There may be images in this book that feature models; these models not necessarily endorse, represent, or participate in the activities represented in the images Any screenshots in this product are for educational and instructive purposes only Any individuals and scenarios featured in the case studies throughout this product may be real or fictitious, but are used for instructional purposes only This publication is designed to provide accurate and authoritative information in regard to the Subject Matter covered It is sold with the understanding that the publisher is not engaged in rendering legal, accounting, or other professional service If legal advice or other expert assistance is required, the service of a competent professional person should be sought Production Credits VP, Product Management: David D Cella Director of Product Management: Michael Brown Product Manager: Sophie Fleck Teague Product Specialist: Carter McAlister Production Manager: Carolyn Rogers Pershouse Production Editor: Brooke Haley Senior Marketing Manager: Susanne Walker Manufacturing and Inventory Control Supervisor: Amy Bacus Composition: codeMantra U.S LLC Cover Design: Scott Moden Text Design: Kristin E Parker Director of Rights & Media: Joanna Gallant Rights & Media Specialist: Merideth Tumasz Media Development Editor: Shannon Sheehan Cover Image (Title Page, Chapter Opener): © ALMAGAMI/Shutterstock Printing and Binding: Command Robbinsville Cover Printing: Command Robbinsville Library of Congress Cataloging-in-Publication Data Names: Sollecito, William A., author Title: Mclaughlin and Kaluzny’s continuous quality improvement in health care / William A Sollecito, DRPH, UNC, Chapel Hill, Julie Johnson, PhD, MSPH, Northwestern University Medical School, Chicago, Illinois Other titles: Continuous quality improvement in health care Description: Fifth edition | Burlington, Massachusetts: Jones & Bartlett Learning, [2019] | Includes bibliographical references Identifiers: LCCN 2018029625 | ISBN 9781284126594 (paperback) Subjects: LCSH: Medical care—United States—Quality control | Total quality management—United States Classification: LCC RA399.A3 C66 2019 | DDC 362.10973—dc23 LC record available at https://lccn.loc.gov/2018029625 6048 Printed in the United States of America 22 21 20 19 18 10 To my home team—Paul, Harrison, Tore, and Elijah –JJ To my family for their loving support always and especially to our newest addition, Mason, who represents the future, which is what this book is all about! –WS © ALMAGAMI/Shutterstock Contents Acknowledgments viii Contributors x Preface xii Foreword xiv Chapter The Global Evolution of Continuous Quality Improvement: From Japanese Manufacturing to Global Health Services Definitions Rationale and Distinguishing Characteristics Elements of CQI Evolution of the Quality Movement The Big Bang—The Quality Chasm 17 From Industrialization to Personalization 18 The Scientific Method of CQI 24 Conclusions 28 References 28 Chapter Factors Influencing the Application and Diffusion of CQI in Health Care 32 The Current State of CQI in Health Care 33 CQI and the Science of Innovation 35 Chapter Integrating Implementation Science Approaches into Continuous Quality Improvement 51 Implementation Science Defined 51 Integrating Implementation into QI: The Model for Improvement and Implementation 53 Implementing Well: Using Frameworks for Implementation 63 Conclusions 65 References 67 Appendix 3.1: Definitions of CFIR Constructs 69 Appendix 3.2: Implementation Strategies and Definitions .73 Appendix 3.3: Categories and Strategies 80 Appendix 3.4: List of Behavioral Change Techniques 82 Chapter Understanding Variation, Tools, and Data Sources for CQI in Health Care 107 Health Care Systems and Processes Gaining Knowledge Through Measurement Quality Improvement Tools Sources of Data for CQI Conclusions References 108 112 124 134 139 140 Kotter’s Change Model 47 Chapter Lean and Six Sigma Management: Building a Foundation for Optimal Patient Care Using Patient Flow Physics 143 Conclusions 48 Lean and Six Sigma Management Defined 144 References 48 Lean Management System (LMS) 157 v The Business Case for CQI 37 Factors Associated with Successful CQI Applications 38 Culture of Excellence 43 vi Contents Conclusions 171 Conclusions 232 References 172 References 232 Chapter Understanding and Improving Team Effectiveness in Quality Improvement 175 Chapter Assessing Risk and Preventing Harm in the Clinical Microsystem 235 Teams in Health Care 179 Risk Management—Background and Definitions 236 High-Performance Teams and Quality Improvement 180 Models of Risk Management 240 Understanding and Improving the Performance of Quality Improvement Teams 182 Resources and Support 189 Engineering a Culture of Safety 240 Applying Risk Management Concepts to Improving Quality and Safety Within the Clinical Microsystem 242 Team Processes 193 Role of Risk Management and Patient Disclosure 249 Conclusions 199 Conclusions 250 References 199 References 251 Chapter The Role of the Patient in Continuous Quality Improvement 201 Patient Involvement in Health Care Improvement: A Brief Overview 202 Rationale for Patient Involvement in CQI 204 Methods for Involving Patients in CQI 205 Factors Affecting Patient Involvement 207 Measuring Patient Involvement in CQI 207 The M-APR Model of Patient Involvement 208 Conclusions 213 References 213 Chapter A Social Marketing Approach to Increase Adoption of Continuous Quality Improvement Initiatives 217 Chapter 10 Classification and the Reduction of Medical Errors 253 Why Classify Safety Events? 255 Skill-, Rule-, and Knowledge-Based Classification 255 Conclusions 267 References 267 Chapter 11 Continuous Quality Improvement in U.S Public Health Organizations: Widespread Adoption and Institutionalization 270 Clarifying Key Terms 271 Hallmarks of Social Marketing 219 History of Actions to Promote CQI in Public Health 272 Social Marketing Applications to CQI in Health Care 220 Factors Affecting the Ongoing Adoption and Institutionalization of CQI in Public Health 273 A Scenario for How to Apply Social Marketing to a Health Care CQI Initiative 225 Conclusions 279 References 279 Contents Chapter 12 Health Service Accreditation: A Strategy to Promote and Improve Safety and Quality 282 An Overview of Accreditation 282 Accreditation: A Common Strategy to Improve Health Organizations and Care 284 vii QI Frameworks and Methods 299 Conclusions 307 References 307 Chapter 14 Future Trends and Challenges for Continuous Quality Improvement in Health Care 311 Accreditation: A Process Promoting Continuous Quality Improvement 285 Setting the Stage for CQI 312 Accreditation Agencies, Standards, and Surveyor Reliability 287 Road Map for the Future 315 Public Health Accreditation in the United States 291 References 329 Conceptual Frameworks for Improving Care 312 Conclusions 327 Conclusions 292 References 293 Chapter 13 Quality Improvement in Low- and Middle-Income Countries 297 Variation in Health Outcomes 297 New Challenges and Opportunities for QI 298 Index .333 © ALMAGAMI/Shutterstock Acknowledgments As we developed the fifth edition of Continuous Quality Improvement in Health Care, we were inspired once again by Drs McLaughlin and Kaluzny While we are very appreciative of their contribution of the Preface, their contribution has been so much greater through the years, as mentors and as colleagues We were also inspired by the thought provoking Foreword written by Dr Paul Batalden where he outlined the model of CQI in improving quality, safety, and value and the model of coproduction in improving the “value of the health care service contribution to better health.” We have benefited greatly from the feedback of students who have provided insight and understanding of the importance of making this book a practical teaching tool that addresses the continuing challenges of improving quality and safety of health care in the future We are most appreciative to our friends and colleagues around the globe who authored chapters The coordination and integration of the contributing authors was a tremendous undertaking and we were privileged to work with excellent colleagues, who are truly expert practitioners of continuous quality improvement in health care The production of the book required a team effort at all levels and in multiple locations We would first like to acknowledge the assistance and guidance of the editorial team at Jones & Bartlett Learning In Chapel Hill, special appreciation goes to Dean Barbara Rimer, of the UNC Gillings School of Global Public Health, whose leadership inspires a learning environment that stimulates innovations and viii the motivation to pursue them Deep appreciation is also given to the faculty and staff in the Public Health Leadership Program at the University of North Carolina and the Center for Healthcare Studies and Surgical Outcomes and Quality Improvement Center (SOQIC) at Northwestern University with whom we shared ideas that led to a better product We especially thank Dr Rohit Ramaswamy, who not only authored two chapters but also shared his wisdom about the current and future trends in CQI globally Finally, we appreciate the feedback and guidance that we received from the readers of the Fourth Edition, which among other things led us to reduce the number of chapters in this edition, but also gave us the incentive to go into greater depth on some of the new topics, such as implementation science While several chapters of the Fourth Edition have been eliminated, we would like to acknowledge several of the authors of those chapters here, as the concepts (listed below) were integrated into this edition’s remaining chapters They include: ■ ■ ■ Vaughn Upshaw and David Steffen—the importance of the learning organization concepts in CQI Anna Schenck, Jill McArdle, and Robert Weiser—the use of Medicare data in CQI and the real-world example of the Clemson Nursing Home Case Study Curt McLaughlin and David Kibbe—the importance of health information technology and understanding the strengths and weaknesses of various data sources used in CQI Acknowledgments Once again, as with CQI itself, the production of this book truly required teamwork and we appreciate and acknowledge the vital ix role of all of our fellow team members, not the least of which includes our families Julie K Johnson, Chicago, IL William A Sollecito, Chapel Hill, NC ... ALMAGAMI/Shutterstock Acknowledgments As we developed the fifth edition of Continuous Quality Improvement in Health Care, we were inspired once again by Drs McLaughlin and Kaluzny While we are very appreciative... Improvement in Health Care was published in 1994 Continuous quality improvement in health care was in its infancy Paul Batalden had kindly educated us, and others, on his philosophy and groundbreaking... Trends and Challenges for Continuous Quality Improvement in Health Care 311 Accreditation: A Process Promoting Continuous Quality Improvement 285 Setting the Stage for CQI